tag:theconversation.com,2011:/fr/topics/disability-and-health-care-31212/articlesDisability and health care – The Conversation2017-09-19T19:38:31Ztag:theconversation.com,2011:article/832962017-09-19T19:38:31Z2017-09-19T19:38:31ZNDIS failing to catch children with late-onset difficulties<figure><img src="https://images.theconversation.com/files/186163/original/file-20170915-16328-1qxl454.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">Early years settings, like preschools and kindergarten, are often the first place social difficulties are identified.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The rollout of the <a href="https://www.ndis.gov.au/">National Disability Insurance Scheme</a> (NDIS) in selected sites in 2016 signified a shift in cultural views about disability. Historical views were based on a medical model derived from deficit, dysfunction and impairment. Today, we ask that building capacity, inclusion and access be the way forward for people and young children living with disabilities. </p>
<p>However, medical evidence is still required to establish entitlement, and some children with late-onset delays miss out.</p>
<h2>Children with late onset delays disadvantaged under the medical model</h2>
<p>Some children are born with congenital risk factors known to cause developmental delays - for example, very low birth weight, hereditary conditions, birth defects or trauma incidents. These factors ordinarily generate specialised monitoring or specific screening to identify issues as soon as possible, to enable families’ access to early childhood early intervention (ECEI). </p>
<p>However, not all delays in child development can be detected at birth or immediately post-partum. Late-onset delays usually present themselves at age two or three. In Australia, a universal approach to developmental health aims to capture this population of children.</p>
<p><a href="http://www.earlychildhoodaustralia.org.au/our-publications/australasian-journal-early-childhood/index-abstracts/ajec-vol-42-no-3-september-2017/national-disability-insurance-scheme-administrators-perspectives-agency-transition-user-pay-early-intervention-service-delivery/">A recent study</a> conducted in a pilot NDIS site found administrators of early childhood early intervention agencies predicted children with late onset delays would be poorly served under this model. </p>
<p>Although developmental health checking is in place, it is grounded in a medical view of “disease prevention” and “risk”, and its effectiveness relies on contact with parents. While the administrators recognised partnerships with families are vital, they expressed concern that parents wouldn’t have the time or the support necessary to understand the impact of late onset developmental disability before having to tick a box to apply for funding. The administrators observed that the NDIS invested little in the individuality of each family and the impact of a child’s difficulties. </p>
<p>For parents of children with late-onset delays, an understanding of developmental concerns should be encouraged and supported in preschool. </p>
<h2>Social disadvantage puts children at a greater risk</h2>
<p>Today, <a href="http://www.jstor.org/stable/41475645?seq=1#page_scan_tab_contents">the rates of children presenting in preschools with delayed development</a> are increasing. This is a result of the cumulative effects of <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1468-3148.2005.00270.x/epdf?r3_referer=wol&amp;tracking_action=preview_click&amp;show_checkout=1&amp;purchase_referrer=onlinelibrary.wiley.com&amp;purchase_site_license=LICENSE_DENIED">environmental factors and patterns of social disadvantage</a>.</p>
<p>Many parents from socially-disadvantaged families were less likely to attend developmental health-checking systems at child and family health clinics. They miss out on developmental health monitoring and information that helps them identify milestones and markers. </p>
<p>Because of this, <a href="http://www.tandfonline.com/doi/abs/10.1080/00223980.2013.853020">challenging behaviours</a> known to be associated with developmental delays and intellectual disability (such as non-compliance, tantrums or aggression) are often accepted in their homes. For these parents, it can be difficult to understand them as developmental concerns. Consequently, social difficulties are only flagged as a problem once their child starts preschool. </p>
<p>If parents can’t understand the significance of developmental milestones, it’s harder for them to understand the notion of being “delayed” or, more importantly, the impact on learning.</p>
<h2>Early childhood educators are well positioned to track development</h2>
<p>Working within the <a href="http://files.acecqa.gov.au/files/National-Quality-Framework-Resources-Kit/belonging_being_and_becoming_the_early_years_learning_framework_for_australia.pdf">Early Years Learning Framework</a> is an essential part of any early educator’s daily work of observing children’s play, interests and social behaviour. Tracking individual progress often leads to conversations with parents arising from evolving developmental concerns about a child over time. </p>
<p>Early years settings, like preschools, are often the first place parents are able to have routine conversations about health information, developmental progress and the wellbeing of their child. </p>
<p>Flagging developmental concerns with parents is never an easy task, especially when it relates to social behaviour. Talking about these concerns may also be at odds with families’ historical views of sickness and/or their experiences of child-rearing. Parents may be reluctant to believe their children has these problems. </p>
<p>Crucially, at the four-year-old stage – late in a child’s development to be identifying delays – empowering parents requires trusting relationships mediated by professional report and observation. Building a family’s capacity to claim for services takes time.</p>
<h2>How can we better support these children and their families?</h2>
<p>Timing for access to ECEI is pivotal to a child’s future learning outcomes. This means we need to change how we view those with late-onset difficulties. A reliance on medical evidence as an entry ticket to the NDIS does little to achieve social justice for these children.</p>
<p>Parents of any child identified with a developmental concern in preschool should consult with a GP or paediatrician. This will mean inevitably going on a waiting list. These waiting lists could further disadvantage children who are already at risk due to social factors, and further compromise their learning opportunities. It also discounts the validity of evidence from qualified early childhood educators. </p>
<p>Being on a waiting list does little to support a sensible outcome for all, especially socially-disadvantaged families. </p>
<p>Supporting documentation from early childhood educators must be repositioned and upgraded to empower vulnerable families to access early intervention services sooner rather than later.</p><img src="https://counter.theconversation.com/content/83296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison M Marchbank does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Parents need support from early childhood educators to build capacity to claim for NDIS services.Alison M Marchbank, Honorary Fellow, Early Childhood Education., Charles Darwin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/780182017-06-27T01:06:20Z2017-06-27T01:06:20ZGOP health care bill would make rural America's distress much worse<figure><img src="https://images.theconversation.com/files/175743/original/file-20170626-3062-1apmidn.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">Rural hospitals, such as this one in Wedowee, Alabama, are struggling to stay open.
</span> <span class="attribution"><span class="source">AP Photo/Brynn Anderson</span></span></figcaption></figure><p>Much has been made of the <a href="http://www.asanet.org/news-events/speak-sociology/more-rural-revolt-landscapes-distress-and-2016-presidential-election">distress</a> and <a href="http://www.reuters.com/article/us-usa-election-michigan-idUSKBN13621W">discontent</a> in rural areas during the 2016 U.S. presidential election. Few realize, however, this is also felt through unequal health. </p>
<p>Researchers call it the “<a href="https://www.ncbi.nlm.nih.gov/pubmed/18556611">rural</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901280/">mortality</a> <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2014.301989">penalty</a>.” While rates of mortality have steadily fallen in the nation’s <a href="http://www.pnas.org/content/113/7/E815.full">urban areas</a>, they have actually climbed for rural Americans. And <a href="http://www.washingtonpost.com/sf/national/2016/04/10/a-new-divide-in-american-death/?utm_term=.314f4a5d0e00">the picture is even bleaker</a> for specific groups, such as rural white women and people of color, who <a href="http://onlinelibrary.wiley.com/doi/10.1111/jrh.12181/full">face persistent disparities in health outcomes</a>. In every category, <a href="https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urban-chartbook-update.pdf">from suicide to unintentional injury to heart disease</a>, rural residents’ health has been declining since the 1990s. </p>
<p>While some have blamed these <a href="https://theconversation.com/six-charts-that-illustrate-the-divide-between-rural-and-urban-america-72934?sr=6">gaping disparities</a> on “culture” or “lifestyle” factors – such as a supposed <a href="https://www.ncbi.nlm.nih.gov/pubmed/21834356">fatalism</a> or overconsumption of unhealthy products like <a href="http://www.salon.com/2012/08/10/dont_put_mountain_dew_in_a_baby_bottle/">Mountain Dew</a> – the truth is that the biggest culprit is limited access to health care and challenging economic circumstances. </p>
<p>The passage of the Affordable Care Act (ACA) in 2010 <a href="https://medium.com/usda-results/rural-health-day-f6aac8ad7be7">began to change this</a> as more rural Americans gained insurance coverage and the government invested more money into regional health facilities and training.</p>
<p>This progress <a href="https://theconversation.com/rural-america-already-hurting-could-be-most-harmed-by-trumps-promise-to-repeal-obamacare-71453?sr=4">is now at risk</a>, however, as the Republican Congress inches closer to repealing Obamacare and replacing it with a feeble alternative that greatly weakens rural health care access. As researchers who study the mental and physical health of rural Americans, we believe this would have disastrous consequences. </p>
<h2>The travails of rural America</h2>
<p>Even as <a href="https://theconversation.com/where-is-rural-america-and-what-does-it-look-like-72045?sr=1">rural America</a> feeds the country, <a href="http://www.npr.org/sections/thesalt/2017/05/22/529493413/in-some-rural-counties-hunger-is-rising-but-food-donations-arent">hunger is on the rise</a> in rural areas. </p>
<p>Some <a href="https://www.iatp.org/files/258_2_98043.pdf">98 percent of rural residents</a> live in food deserts – defined as counties in which one must drive more than 10 miles to get to the nearest supermarket. This makes it challenging to maintain healthy and nutritious diets, leading to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481194/">higher rates of obesity in rural areas</a> that greatly increase the risk for diabetes, heart disease and certain cancers.</p>
<p>As rural workers struggle to <a href="https://www.wsj.com/articles/rural-america-struggles-as-young-people-chase-jobs-in-cities-1395890099">sustain employment</a> in a <a href="https://www.washingtonpost.com/news/wonk/wp/2016/05/22/a-very-bad-sign-for-all-but-americas-biggest-cities/?utm_term=.174ccab19701">shifting economy</a>, the increasing poverty is contributing to mental distress and <a href="http://journals.sagepub.com/doi/abs/10.1177/002204260703700302">substance use</a>. On a larger scale, the economic changes that have hit rural areas have resulted in a declining tax base, lower incomes and strained educational institutions. Together, they challenge rural residents’ health not just in the immediate term but cumulatively over their lives. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=754&amp;fit=clip" srcset="https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=600&amp;h=428&amp;fit=crop&amp;dpr=1 600w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&amp;q=30&amp;auto=format&amp;w=600&amp;h=428&amp;fit=crop&amp;dpr=2 1200w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&amp;q=15&amp;auto=format&amp;w=600&amp;h=428&amp;fit=crop&amp;dpr=3 1800w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=754&amp;h=538&amp;fit=crop&amp;dpr=1 754w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&amp;q=30&amp;auto=format&amp;w=754&amp;h=538&amp;fit=crop&amp;dpr=2 1508w, https://images.theconversation.com/files/175505/original/file-20170625-13475-1udmu6z.jpg?ixlib=rb-1.1.0&amp;q=15&amp;auto=format&amp;w=754&amp;h=538&amp;fit=crop&amp;dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Like many other rural hospitals in the U.S., Evans Memorial in Claxton, Georgia, has struggled to keep its doors open while treating patients who tend to be older, poorer and often uninsured.</span>
<span class="attribution"><span class="source">AP Photo/Russ Bynum</span></span>
</figcaption>
</figure>
<h2>Barriers to accessing health care</h2>
<p>Yet, despite all these medical issues, rural residents have a tough time getting the health care they need.</p>
<p>The nature of rural employment, for example, is characterized by <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1748-0361.2005.tb00058.x/epdf">self-employment, seasonal work and lower-than-average pay</a>. This means rural workers are <a href="https://www.ruralhealthinfo.org/pdf/research_compendium.pdf">less likely to get insurance through their jobs and thus face higher premiums</a> when buying their own policies. </p>
<p>The lack of public transportation in most rural areas is also a major hurdle to seeing a doctor, particularly as residents <a href="https://www.ncbi.nlm.nih.gov/pubmed/16606425">have to travel much farther</a> than those in urban areas to reach health care providers.</p>
<p>Rural residents get most of their services through primary care providers, <a href="http://pediatrics.aappublications.org/content/118/1/e132">who take on the work of other practitioners</a>, like behavioral health clinicians, due to longstanding specialist shortages. When handling <a href="http://www.sciencedirect.com/science/article/pii/S0033318207710265">numerous complaints</a> during a single medical encounter, primary care providers may concentrate on the most acute health concerns of their patients, undermining the ability to diagnose all their conditions and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3609543/">meaningfully discuss their larger health risks</a>, such as exercise, weight and substance use. When providers are rushed or deliver sub-par care, rural residents may wonder if seeking it out is worth the challenge, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27322157">opting to struggle on their own</a>. </p>
<p>These and other constraints make it tougher for rural Americans to get the screenings necessary to spot serious diseases such as <a href="http://www.tandfonline.com/doi/abs/10.1300/J013v42n02_06">cancer</a> early or to maintain adequate followup on conditions like <a href="https://www.ncbi.nlm.nih.gov/pubmed/24183213">hearing loss</a>. Finding the regular medical care necessary to manage chronic conditions, such as diabetes, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27322157">depression</a> or <a href="https://www.hrsa.gov/advisorycommittees/rural/publications/opioidabuse.pdf">opioid disorders</a>, is even more challenging. </p>
<p>Rural health care has at times been <a href="https://www.ncbi.nlm.nih.gov/pubmed/18709749">characterized as patchwork</a>. In part, that’s because the <a href="https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/30/10/36/rural-health-goals-guaranteeing-a-future">costs of sustaining health care infrastructure in rural areas are higher</a> thanks to the large service areas, the inability to negotiate bulk pricing and lack of financial incentives to fill in provider gaps. </p>
<h2>The ACA and the AHCA</h2>
<p>The ACA, intended to turn this around, has in fact led to dramatic gains in insurance coverage among rural Americans. </p>
<p>Broadly speaking, insurance rates in rural areas <a href="http://hrms.urban.org/quicktakes/Substantial-Gains-in-Health-Insurance-Coverage-Occurring-for-Adults-in-Both-Rural-and-Urban-Areas.html">reached almost 86 percent</a> in early 2015, up from an estimated 78 percent in 2013.</p>
<p>In Kentucky – a state with high poverty, a large rural population (42 percent of residents) and a successful <a href="https://theconversation.com/love-it-or-hate-it-obamacare-has-expanded-coverage-for-millions-66472?sr=2">Medicaid expansion</a> initiative – <a href="http://www.cbpp.org/blog/medicaid-at-50-kentuckys-experience-highlights-benefits-of-medicaid-expansion">tens of thousands of newly insured low-income adults</a> began using preventative services after previously being unable to afford it. The state’s uninsured fell by half and, as a result, <a href="http://content.healthaffairs.org/content/35/1/96.abstract">fewer people skipped taking their medications</a> due to financial hardships relative to other states that didn’t expand Medicaid. </p>
<p>The ACA also <a href="http://www.scholarsstrategynetwork.org/brief/how-obamacare-repeal-would-harm-rural-america">strengthened rural health care institutions</a> by investing in upgrades to hospitals and clinics, preventative health programs and support for providers to stay in rural areas. While rural hospitals are often laden with the expense of providing extensive care without payment to indigent patients, rural hospitals in states that expanded Medicaid under the ACA <a href="http://www.cbpp.org/research/health/house-passed-bill-would-devastate-health-care-in-rural-america?utm_source=CBPP+Email+Updates&amp;utm_campaign=d303d5c441-EMAIL_CAMPAIGN_2017_05_16&amp;utm_medium=email&amp;utm_term=0_ee3f6da374-d303d5c441-110964945">finally were able to better balance their books when caring for this vulnerable group</a>. At the same time, the ACA supported innovative models ideal for rural areas that prioritized <a href="https://www.ncbi.nlm.nih.gov/pubmed/18709749">outreach</a>, <a href="http://content.healthaffairs.org/content/29/5/852.abstract">integration of services</a> and <a href="http://nashp.org/wp-content/uploads/2016/09/Rural-Opioid-Primer.pdf">collaboration between safety-net players</a>.</p>
<p>Both the <a href="https://www.washingtonpost.com/graphics/2017/politics/obamacare-senate-bill-compare/">House and Senate</a> bills to repeal and replace Obamacare would <a href="http://www.scholarsstrategynetwork.org/brief/how-obamacare-repeal-would-harm-rural-america">drastically reduce rural Americans’ insurance coverage</a> and significantly threaten the ability of <a href="http://www.npr.org/sections/health-shots/2017/06/22/533680909/republicans-proposed-medicaid-cuts-would-hit-rural-patients-hard">many rural hospitals and clinics to keep their doors open</a>. <a href="http://www.cbpp.org/research/health/house-passed-bill-would-devastate-health-care-in-rural-america">Analysts show</a> that the bill would provide insufficient tax credits to pay for rural premium costs, drastically increase the price of rural premiums and increase uncompensated care in rural hospitals. </p>
<h2>What rural areas need from health care reform</h2>
<p>Previous efforts at health care reform show us that rural areas are uniquely vulnerable. Efforts need to take account not only of coverage and access – as has been the focus of the current debate – but also how reform affects rural health care institutions and the larger social factors shaping overall health.</p>
<p>The particular economic factors affecting rural health care institutions <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415203/">make rural areas particularly vulnerable to political shifts</a> that disrupt services for existing patients and for those newly insured, creating immense challenges for rural providers. Steps that fail to account for the impact of financial hardship on these institutions not only hurt their bottom line but contribute to <a href="https://www.ncbi.nlm.nih.gov/pubmed/22229021">poor morale and workforce turnover</a> and larger-scale decisions to reduce services, which decrease their ability to address patient needs. </p>
<p>At the same time, commitment to improving the health of rural Americans requires attention to the so-called upstream factors shaping rural health. That means <a href="http://www.prnewswire.com/news-releases/medicaid-plays-a-more-significant-role-in-small-towns-and-rural-communities-than-in-metro-areas-300469734.html">preserving the safety net programs so vital in rural areas</a> with underemployment and low-paying jobs, <a href="http://www.soar-ky.org/about-us">strengthening rural economies</a> and investing in <a href="https://www.brookings.edu/blog/brown-center-chalkboard/2017/01/04/a-better-future-for-rural-communities-starts-at-the-schoolhouse/">high-quality education</a>. </p>
<p>If our leaders are serious about reform that will lessen the rural-urban mortality gap, they should recognize the unique needs of rural America and ensure health care policy reflects how vital access to quality care is to their financial success – not to mention their well-being.</p><img src="https://counter.theconversation.com/content/78018/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health outcomes for rural Americans have steadily deteriorated in recent decades even as they've improved elsewhere. The GOP plan to replace the Affordable Care Act will worsen the problem.Claire Snell-Rood, Assistant Professor of Public Health, University of California, BerkeleyCathleen Willging, Adjunct Associate Professor of Anthropology, University of New MexicoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/643112016-09-14T21:18:31Z2016-09-14T21:18:31ZThe triple vulnerability of being poor and disabled in rural South Africa<figure><img src="https://images.theconversation.com/files/137589/original/image-20160913-4948-um4tr9.jpg?ixlib=rb-1.1.0&amp;q=45&amp;auto=format&amp;w=496&amp;fit=clip" /><figcaption><span class="caption">People with disabilities living in Madwaleni in the Eastern Cape have difficulty accessing healthcare. </span> <span class="attribution"><span class="source">Richard Vergunst</span></span></figcaption></figure><p>Over the last two decades the South African government has passed several pieces of legislation to ensure that people with disabilities are included in society and are able to access services such as health care.</p>
<p>This has included a <a href="http://www.gov.za/services/social-benefits/disability-grant">national disability grant</a> as well as regulations that all government buildings provide ramps so that people with disabilities can easily access them.</p>
<p>According to official statistics <a href="http://www.statssa.gov.za/?p=3180">7.5%</a> of South Africans live with disability. In the rest of the world, this figure sits at <a href="http://www.who.int/disabilities/world_report/2011/report/en/">15%</a>. It’s quite possible that the South African figure doesn’t reflect the full extent of disability in the country because of under-reporting. </p>
<p><a href="http://www.who.int/disabilities/world_report/2011/chapter3.pdf?ua=1">Global studies</a> show that the top three barriers stopping people with disabilities from using health facilities are cost, lack of services near to where they live and transportation.</p>
<p><a href="http://scholar.sun.ac.za/bitstream/handle/10019.1/98408/vergunst_access_2016.pdf?sequence=1">Our study</a> found that these three barriers were particularly acute for poor people with disabilities living in rural South Africa. This is because they experience a “triple vulnerability”: poverty, disability and rurality. They see themselves as less healthy compared to able bodied people and they have less access to health care.</p>
<h2>A community with very little</h2>
<p>Our study formed part of the international study <a href="http://www.sintef.no/Projectweb/Equitable">Equitable</a>. This looked at access to health care for people with disabilities, evaluating 16 sites in South Africa, Namibia, Malawi and Sudan.</p>
<p>Our part of the study centred on Madwaleni in the Eastern Cape, a largely rural and poor province in South Africa. We looked at the differences between people with and without disabilities when it came to accessing health care. </p>
<p>Madwaleni is made up of about 20 villages scattered around rugged hills, valleys, rivers and forests. The area lacks basic services like water and electricity and has poor infrastructure. Nearly 90% of the community is unemployed and there are low levels of literacy and education. There is a high incidence of communicable diseases and high mortality rates.</p>
<p>There is a hospital which handles cases in a 35km radius as well as eight smaller health care centres. Together they service the 120 000 people living in the area. </p>
<p>Poor people with disabilities have more problems going about their daily activities than those who are able bodied. Travelling around their communities, shopping, preparing food and doing household chores are more challenging. They also have problems furthering their education and getting jobs and often experience prejudice and discrimination.</p>
<p>In a rural, remote and impoverished communities these challenges are more amplified. The people with disabilities in these settings experience such issues more intensely. </p>
<h2>Physical barriers</h2>
<p>In Madwaleni the topography of the area, the natural environment and the terrain all contribute to the experiences of people with disabilities. Many have to manage hills, cross rivers or use gravel and uneven roads to access health care. </p>
<p>The distances are vast between the eight smaller health centres and the villages in the area. Travelling on foot is often not an option and taxis are expensive. The result is that people with disabilities receive health care less often and in turn feel that they have poorer physical and mental health.</p>
<p>In addition to transportation problems, there are other physical barriers. For example, participants recounted how they were unable to use overnight accommodation at health care centres and were not provided with the drugs and equipment they needed after their consultations. </p>
<h2>Bad attitudes</h2>
<p>In addition to these challenges, participants said they encountered negative attitudes from health care providers who treated them differently from other patients. </p>
<p>People with disabilities felt their preferred health care providers were not as accessible to them as their able bodied peers. They also did not receive the same level of service and were unhappy with health care personnel.</p>
<p>They communicated less with health care providers and as a result felt that they received less respect from these providers. This often meant that they were afforded less privacy during consultations when compared with able bodied patients. This meant that health care providers did not spend time explaining things to them. They also felt that they were less involved in their own treatment. </p>
<h2>Improving the situation</h2>
<p>Based on the site study in Madwaleni, there are several changes that could improve the way rural people with disabilities access health care. </p>
<p>Mobile health clinics would help. This would mean that people with disabilities could access health care services more regularly. </p>
<p>In addition, health care workers should be trained to better deal with people with disabilities so that attitudinal barriers can be addressed. </p>
<p>And lastly, the community needs to be educated about disability and how it can help create a more inclusive environment.</p><img src="https://counter.theconversation.com/content/64311/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Vergunst does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Poor people with disabilities living in rural South Africa are particularly disadvantaged when it comes to accessing health care.Richard Vergunst, PhD Psychology Department, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.